Compression Pumps for Lymphedema Treatment

Put a crowd of lymphedema patients, therapists and doctors together and nothing will start a heated debate like the topic of using pneumatic compression pumps for the treatment of lymphedema.

Compression pumps were at one time a standard of treatment for lymphedema. These older types referred to simply as compression pumps consist of an inflatable garment for the arm, leg, or foot and an electrical pneumatic pump that fills the garment with compressed air. The garment is intermittently inflated and deflated with cycle times and pressures that vary between devices.

These antiquated devices have been replaced by intermittent/ sequential pumps which consist of numerous chambers that inflate one at a time while moving up the arm or leg. Due to complications such as genital lymphedema and possible further damage to existing superficial lymphatics, many patients and medical professionals are no longer in favor of using compression pumps to treat lymphedema.

Time for a new dialogue and re-evaluation?

Today, however, there is a new generation of compression devices coming in to the market that offer the possibilities of a safe and effective addition to our treatment arsenal.

My hat is off to two companies in this regard.

First, Tactile Systems for their Flexitouch Device and BioCompression for its development of pneumatic compression therapy that uses the Reid Sleeve Optiflow insert which has been demonstrated to not damage the superficial lymphatics.

Factors for Consideration in Using a Compression Pump

The question about compression pumps is not whether they are effective in the movement of fluid. This has been clearly demonstrated and without a doubt they are extremely effective. The central problems are the possible complications.

The clinically demonstrated complications as mentioned above are (1) genital lymphedema because devices have not cleared the abdominal lymphatics before use of the pump and (2) damage to the superficial lymphatics.
It is also my personal opinion that the use of pneumatic compression devices must not be marketed as a replacement for manual decongestive therapy by a certified lymphedema therapist or for a substitution in the use of compression bandaging… Rather, it should be used as adjunct for maintenance and should be included in the overall patient self-care program.

It is also important to understand the difference between treatment for arm lymphedema versus leg lymphedema.
It is my utmost desire to provide important and independent information for patients as they decide whether or not to use a compression device.

Competing Interests

At the time of publication, the author of this article and editor of this page has no competing interests and has received no renumeration or compensation for the information provided.

Compression Pumps for Arm Lymphedema

It has been substantially demonstrated through various studies that the best treatment for arm lymphedema is actually a combination of manual decongestive therapy, compression bandages and the use of a compression pump.

In my personal opinion, I have no problem recommending this treatment modality.

Compression Pumps for Leg Lymphedema

The complications listed above have centered around the use of compression pumps for the leg lymphedema.
Hopefully, the two new devices manufactured by Tactile and by BioCompression will resolve these issues.

Those of us with leg lymphedema desperately need some time of additional treatment option that not only helps but that we can feel totally safe using.

Contraindications for the use of a compression pump

A compression pump should not be used if:

You have an active infection

You have a blood clot or deep venous thrombosis

You have kidney or renal failure

You have congestive heart failure

You have body-wide edema

You have plueral effusions (lung fluid)

You have episodes of pulmonary embolism

You have thrombophlibitis

You have pain or numbness of the extremity

You have severe peripheral arteriosclerosis or other ischemic diseases

You have gangrene

You have dermatitis

You have untreated infected wounds

You have recent skin grafts

You have known or suspected acute deep vein thrombosis or thrombophlebitis

Should I use a Sequential Pump?

Opinion Article

While there have been clinicians, therapists, and patients who have not had good results with pumps and do not recommend their use, hundreds of people have experienced great results with the proper use of the right pumps. Pumps are not for everyone, and success does depend on which pump is used, and the proper application of pumps. Pumps, like prescription drugs, or even like driving a car, if not used properly can cause damage, or will not achieve results. In providing lymphedema therapy for thirteen years, helping hundreds of people, I have never seen some of the problems some people are reporting. Many of the people I have worked with have successfully used their pump for five to ten years with no complications.

THE KEY IS USING THE RIGHT PUMP, THE RIGHT WAY.

Some therapists may tell you that pumps are a waste of money, that they do not work, that they do not help in opening up lymphatic flow, or that pumps make edema worse. Only part of this is true. When any clinician gives you information on clinical treatment, ask to see scientific clinic studies. Many “opinions” have been published, but no scientific clinical studies have been conducted or published that will back up these statements. There are however, many many scientific, clinical, published studies that prove the efficacy of pumps. Pumps also do not assist in opening up the lymphatics, nor were they designed to, nor are the recommended as such. Pumps are to be used as an alternative for bandaging, and MLD is applied to open up the lymphatic system. It is not appropriate for any clinician or patient to deprive you of any treatment that may really help you, by providing you with misinformation. If your disease is not properly treated and managed, serious health complications can occur. If a pump will assist you in accomplishing effective disease management, and your are given misinformation regarding their effectiveness, this is call for serious concern. Pumps have been clinically proven, beyond opinion, to help hundreds of thousands of people worldwide, but it is important to make sure you are a candidate, make sure you use the right pump, and make sure you use your pump correctly. It is not complicated, and I will review pump information below.

When reviewing pumps, look for a pump that contains ten or more chambers, operates on a short thirty-second cycle time, and applies graduated compression. The body operates on a pressure gradient system, so it is essential to obtain a gradient or graduated compression pump. Gradient or graduated means the pressure at the feet or hand is greater than the thigh or shoulder. Pressure starts at 60mmHg, and is about 1.5% less each chamber as compression moves proximal or towards the thigh or shoulder. Pumps that contain more chambers, and operate on a thirty second cycle versus sixty second cycle more closely mimics massage, and do not over compress the superficial lymphatics. Pumps that are not gradient, operate on a sixty second cycle and contain less than ten chambers can cause a reflux of fluid in the distal veins, and damage the superficial lymphatics. This has been proven upon review of pump compression during Doppler Ultrasonography. The result of this is pain, and edema that does not reduce but actually gets worse. Also, pressures should not be set higher than 60mmHg.

Doppler Ultrasonography shows that when external pressures are applied above 60mmHg, venous flow decreases rather than increases. The goal is to increase venous return in order to remove excess edema causing fluid. When venous return decreases, so does lymphatic flow.

Unless you have no other alternative, do not accept a pump from a supplier who is going to ship it to you or drop it off at your door step. Pumps should be set up in your home, and the provider should properly educate you on the proper use of the pump. If your health insurance company requires you to use an in-network provider who will not provide home set-up, have your physician include “home-set-up and patient education”, in his written prescription for your pump.

Pumps should not be applied over compression bandaging or compression stockings. They should be applied for about two hours in the morning, and two hours at night during treatment, and then as needed for continued edema reduction. Pumps should not be used during sleep over night, unless you are hospitalized, and your physician is directly monitoring treatment. I recommend the use of a Reid Optiflow, Jovi-Pak or Tribute for use with sequential pumps. These foam compression binders can be very effective in protecting the superficial lymphatics, and assisting the direction of lymphatic flow. Manual lymph drainage should also be applied either before and after pump therapy, or during pump therapy. If you have genital edema, or edema in the hips waist and abdomen, the LymphaPress pump has a bodysuit appliance that applies compression from the feet to the chest area. This has assisted my patients in significant abdominal reduction of edema.

You should not use a pump if you have edema throughout your entire body, if you have a blood clot, if you have an active infection, if you have (kidney)renal failure, if you have active cancer, if you have congestive heart failure, or if you are not applying manual lymph drainage. Pumps are also not normally recommended for babies, or children under age six.

Cyndi Ortiz, Lymphedema Therapist

Compression Pumps: Frequently Asked Questions

What is the importance of of having a sequential gradient pump?

Sequential pumps with calibrated gradient pressure have proven to be the best devices for reducing the lymphatic fluid from the limb in acomfortable and efficient manner. These pumps function in much the same manner as the body does by utilizing the muscle pump. The body uses various muscle groups to move the lymphatic fluid through the channels. Unlike the vascular system, the lymphatic system does not have a built-in pump. The vascularsystem has the heart to pump the blood through the body. The lymphatic system relies on the muscle groups to rhythmically move the fluid through the body.

How do I set the pressure on the pump?

Take the patients blood pressure if possible. The lower of the two pressures is the diastolic blood pressure. If its 120/80, 80 would be the diastolic pressure.

The pumps pressure should never be set to exceed the patients diastolic pressure. The pumps pressure in fact should be set 15%-20% or more below the patients diastolic pressure. Exceeding this pressure will over pressurize the tissues by overcoming the body's own innate pressure. It is appropriate to start at a lower pressure (15mmHg below diastolic) and set the pump according to the patients comfort. Higher pressures are not always better. You can increase the pressure if the patient feels comfortable or if you need higher pressures to overcome fibrosis and other related conditions. Most Lymphedema Therapists recommend Arm patients should generally not go above 40mmHG of pump pressure.

How long do I use the pump?

Patients should try to use the pump from one to four hours daily. It is more advantageousto pump in the evening before bedtime. If the patient needs to break up treatment they should divide it into two sessions twice daily. From thirty minutes to as much as two hours in the morning, and a similar amount in the evening before bedtime. They will usually start using the pump every day for one to two hours. After they reach a plateau they can start a maintenance schedule of every other day, to every second day and then twice weekly. Every patient is different and are treated appropriately. No changes in therapy should be made without authorization from the patients physician.

What is the application of the pump for treating ulcers and open wounds?

The pumps can be used on patients with venous ulcers or open wounds aslong as there are no signs of infection or cellulitis. The wound or ulcer must be covered with a sterile dressing material to catch any fluid forced out of the site. If an infection occurs you should never put the pump on a patient or massage the limb as this will move the infected fluid back into the body.

The pump is contraindicated when an infection is present.

How do I check for signs of an infection?

Just about everyone has had an infection at some point in their life. The signs of an infection are localized swelling, pain, redness, pus formation,red streaks and scab formation. There is usually evidence of an injury such asa cut or bite of some sort. Cellulitis, however, is not as easy to identifybut is much more serious. The signs and symptoms of cellulitis are mottled redness, (sunburned appearance), usually over a muscle group, heat blisters or pinpoint rash. Cellulitis usually is not painful at the onset, however most patients will experience substantial pain shortly thereafter. The patient may complain of flu-like symptoms or nausea and dizziness. If any of these symptoms are present, do not use the pump on the patient. Instead call the doctor immediately. This condition will require the patient to be placed on antibiotics for at least 10 to 14 days. A broad-spectrum antibiotic is usually prescribed.

The problem with cellulitis is that it may appear without the presence of any injury: the patient may have taken a plane trip, moved furniture, raked leaves or bowled in a league game. Some factor or combination of factors cause the limb to be stressed resulting in a flare up of cellulitis. Also, patients who have chronic sinusitis or strep throat infections are at risk for developing cellulitis especially if edema is present in the upper limb. Stress the importance of having the patient inspect the skin after bathing and the importance of treating all injuries as potentially serious ones.

How are compression garments used in treating Lymphedema?

Compression garments are specially designed to maintain and support the limb, not to reduce its size. Garments must be applied in the morning to prevent gravity from pulling fluid down into the limb. If
this happens the garment will trap the fluid and the garment will not fit comfortably. The patient should use rubber gloves to help in the application of the garment, as these will provide resistance. Garments should be worn daily and removed at night. Compression garments are available in standard and custom styles. There are several companies to choose from with the final choice usually coming down to cosmetics and cost. Garments usually last about 6 months, at which time it is necessary to be re-fitted. The patient should be re-measured each time a new garment is ordered to account for any changes in the size of the limb, (larger or smaller). The garments are machine washable but seem to last longer when hand washed. The patient will know it is time to get re-fitted when they notice that their limb tends to swell slightly at the end of the day or they notice any signs of stretching in the garment fabric. Recent Medicare rulings require that this type of therapy (custom garments not mandatory) be tried for 30 days and not be be fully effective before pump therapy is approved for use. This is in contrast to the former regulation which listed pump therapy as a last resort.

How does bandaging or wrapping control Lymphedema?

Bandaging and wrapping is a more recent innovation in the U.S. although it has been used in Europe for quite some time. This treatment utilizes a four-layer wrap to work in conjunction with the pump and compression garment in controlling edema. All the digits (fingers and toes) are wrapped individually. The hand or foot is then wrapped, followed by the forearm/calf, elbow/knee,upper arm and thigh. This therapy can be taught to some patients, however older patients or those with limited dexterity i.e.: arthritis, etc. may have difficulty applying these garments. The bandages are reusable. This is important because the bandages are not stocked by every medical supply company and are expensive. Those patients who are able can wrap their limb at night and in the morning take off the wrap and put on their compression garment. They must take the wrap off to use the pump. Many patients often use custom high density foam garments known as The ReidSleeve¨, Tribute Garment, Circaid, JoviPak, MedAssist to as an easier to apply night time compression to replace the bandaging.

What is Manual Lymphatic Drainage?

MLD or Manual Lymphatic Drainage: This is a specially designed massage therapy developed to reduce lymphedema. It is effective in reducing edema of the body, head, neck and limbs. Used in conjunction with sequential pumps with calibrated gradient pressure, MLD can help give the patient pain reliefand expedite reduction of edema in the limb. The recommended treatment schedule varies with each therapist, but is often twice a day for two weeks or more, followed by once a day for two weeks, and then in intervals necessary to maintain the edema at a minimum level. Sessions can cost anywhere from $65.00an hour and up. Some therapists require the patient to have intensive treatment for one month then move on to amaintenance schedule. Patients can learn a variation of MLD which they can perform on themselves, however, much like bandaging this is dependent upon the patients age and/or physical ability.

How important is hygiene for Lymphedema patients?

The patient must be taught meticulous skin care especially with the edematous limb. Because of the increased fluid levels under the skin, the skin cannot resist rips and tears in the same manner as non-edematous skin. Any breakdown in the integrity of the skin results in susceptibility to bacteria, infection and cellulitis, the most serious of complications facing the patient. Teach the patient to treat all cuts, burns, bruises, hangnails, ingrown toenails, ingrown hairs, razor rashes, blisters, scrapes, mosquito bites, etc., as potential sites for infection. Should the patient notice any signs or symptoms of infection or cellulitis they should contact their doctor immediately. Delay in treatment will enable the infection to spread to other areas throughout the body.

The Role of Pneumatic Compression Pumps Preliminary Results From a Current Study

Andrzej Szuba, researcher with the Stanford/Aurora Centre for Lymphatic and Venous Disorders, Stanford University School of Medicine, Stanford, CA U.S.A. has made a number of presentations documenting this centre's experiences in using pneumatic extremity pumps on patients with post-mastectomy lymphedema.

Sept. 14-17, 2000 The Role of Pneumatic Compression Pumps, a presentation at the 4th National Lymphedema Network Conference in Orlando, Florida. Szuba suggested that intermittent penumatic compression with single or multi-compression with single or multi-chamber pumps effectively removed access fluid from the extremity. He reported that they were conducting two studies on the application of pneumatic compression in combination with decongestive lymphatic therapy (DLT) in patients with arm lymphedema secondary to breast cancer therapy.

Preliminary results of the first study involving 22 women showed an average arm volume reduction of 51% in the group using the compression pump with DLT vs.35% volume reduction in the group treated with DLT alone. The second study of 23 which assessed the usefulness of daily sequential compression for maintenance of arm volume by patients with post mastectomy arm edema also found beneficial effects.

Sept. 2002 at the Internation Congress of Lymphology, Genoa, Italy, Szuba, R. Achalu and S.G. Rockson reported on their continued research in this area.

They investigated the safety and efficacy of adjunctive intermittent pneumatic compression (IPC) for the acute decongestive therapy of post-mastectomy lymphedema. 23 patients were randomized into two groups: the first which received decongestive lymphatic therapy (DLT) which included manual lymph drainage, bandaging and exercise daily and IP; and the second which received IPC 30 minutes daily at 40-50 mm. In group 1, 11 patients received a 25% acute arm volume reduction; in group II 12 patients received a mean volume of 45.3% mean volume reduction.

These preliminary results appear to show positive affects for some patients which use this form of treatment.

Sequential compression pumping

Pneumatic pumps with attachable compartmentalized sleeves offer another adjunctive treatment for enhancing lymph flow and resorption. The pump inflates the chambers sequentially in a distal to proximal direction, to move the stagnant lymph in a peristaltic-type rhythm. (Note: The patient should manually clear the trunk and proximal areas prior to, during, and after pumping to provide a reservoir for lymph moving out of the limb. Pumping can be dangerous if one does not transport the fluid to a cluster of operative lymph nodes.) Pump pressure generally should not exceed 40 mm Hg.14 A patient may pump from 30 to 45 minutes several times a day. Contraindications to pumping include deep vein thrombosis within the past year, cellulitis or acute infection of the affected limb, congestive heart failure, respiratory insufficiency, and instances where increased venous and lymphatic return is undesirable, e.g. trunk edema, swollen genitals, diabetes, and primary lymphedema.

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Pneumatic Compression Pump Types

Pneumatic compression pump devices are classified as one of three types3. These three basic types are:

1. Type I—nonsegmented or single compartment pumps with a single outflow port

2. Type II—segmented or multi-chamber devices with multiple outflow ports and sequential filling of the chambers at a fixed pressure

3. Type III—segmented or multi-chamber devices with multiple outflow ports and sequential filling of the chambers with manual control of pressure parameters.

It is important to note that Type II compression pumps are set up to deliver either the same pressure in each chamber segment or a preselected pressure gradient in each chamber segment. However, specific chamber pressures cannot be programmed by the clinician. In comparison, type III compression pumps may be programmed by the clinician to deliver specific levels of compression over particular inflation and deflation cycles. Some type III pumps allow the clinician to program specific levels of compression across each chamber segment.

Pneumatic compression devices consist of an inflatable garment for the arm, leg, or foot and an electrical pneumatic pump that fills the garment with compressed air. The garment is intermittently inflated and deflated with cycle times and pressures that vary between devices.

A non-segmental pneumatic compressor (E0650) is used with appliances/sleeves coded by E0655-E0666 or E0671-E0673. Segmental pneumatic compressors (E0651 or E0652) are used with appliances/sleeves coded by E0667-E0669.

When a foot or hand segment is used in conjunction with a leg or arm appliance respectively, there should be no separate bill for this segment. It is considered included in the code for the leg or arm appliance.